ADDRESS 
ON 
OPHTHALMOLOGY. 
BY 
C. S. TURNBULL, M. D., 
PHILADELPHIA. 
REPRINTED FROM THE 
Transactions of Pei) 15a. State Medical Society, 
NINTEENTH SESSION, 
HELD AT BEDFORD PA., JUNE, 1887. ADDRESS ON OPHTHALMOLOGY. 
BY 
C. S. TURNBULL, M. D., 
PHILADELPHIA. 
[Reprinted from the Transactions of the Medical Society of the State 
of Pennsylvania for 1887.] 
PHILADELPHIA: 
188T. ADDRESS ON OPHTHALMOLOGY. 
C. S. TURKBULL, M. D., 
PHILADELPIIIA. 
Although the title of our address as announced would lead ophthal- 
mologists to expect a specifically special paper on the subject, we 
have deemed it more fitting to bear in mind, and will attempt to an- 
swer, the queries so often put by visiting colleagues : “ Well Doctor, 
what is new on the eye ? ” With this idea in view, therefore, we 
present a melange which at least will be practical, and we hope in- 
structive, as we quote from experience, and have made particular 
reference to the eyes of children. 
“As a warning to slovenly parents, Baudry (Arch. d’Ophth., 
1885, vol. v, p. 55), notes the transmission of syphilis to two 
children by adults, who tried to remove with saliva the crusts along 
the margin of the lids, due to blepharo-conjunctivitis. In both 
cases the chancre was situated near the inner canthus, once above 
and once below.” 
Red eyelids, so called “weak eyes” with or without crusts, and 
loss of lashes, barometer-like, indicate faulty vision, or an error of 
refraction. Marginal eczema, as this form of inflammation of the 
lids is called, can be temporarily cured by local applications, but will 
be apt to return, because, as we have said, an error in refraction is 
generally the remote cause, and glasses must be fitted to remove the 
eye strain. 
As a local application nothing is better than what is known as the 
“ yellow salve,” the composition of which we will give at once: 
Muriate of morphia 1 grain. 
Yellow oxide of mercury 2 grains. 
Yaseline 3 drachms. 
S.—Mix thoroughly and dispense in a collapsible tube. 
Unless this salve be properly applied, it is apt to be found too 
stimulating, and will aggravate the trouble it is intended to re- 
lieve. Each evening the eyelids must be thoroughly bathed with 
warm water, until the crusts can be removed without tearing out the 
eyelashes. Having cleansed the lids from all secretions, they must be 4 
ADDRESS ON OPHTHALMOLOGY. 
carefully dried with a soft linen cloth. Then the edges of the lids 
are to be carefully anointed with a small scrap of the ointment (a 
piece the size of two pins’ heads). The following morning any 
superfluous salve may be gently wiped away with a dry cloth. 
One other symptom of a strained eye, is the “stye” or abscess 
of the meibonian follicle, and unless “Job’s comforters” be gener- 
ally outcropping corporeally, the sight should be carefully tested. 
Furuncles of the lids are to he treated the same as when found on 
other parts of the body, but must not be taken for styes. Neglected 
styes are the constant source of tumors of the eyelids, and no such 
abscesses of a gland should be allowed to slowly subside into a de- 
formity, when by free incision, or by hot applications, they can be 
evacuated spontaneously. 
Obstructions of the tear-duct are generally caused by irritation, 
and the extension of inflammation from nasal disease, or by exposure. 
Most obstructions are at the mouth of the tear duct (punctum), and 
seldom require more than the slitting of the canal. Obstructions 
caused by nasal disease have their origin in the nasal end of the 
duct, and are usually accompanied by blennorrhoea of the lachrymal 
sac. Such cases call for more than ordinary treatment, which to be 
of avail must be started in the nose. The secret of the successful 
treatment of inflammation of the tear sac and multiple stricture of 
the duct, is free slitting of the canal, and division of the mouth of 
the sac down through the bony foramen. In the majority of cases, 
astringent collyria (such as sulphate of zinc, 4 grains to 6 drachms of 
water), and thorough inunction of the nose (inside and out) usually 
effects a cure. More harm than good comes of the use of most forms 
of probes. Small probes are dangerous, as they make false passages; 
but where there is a decided stricture, free division, as we have ad- 
vised, and large probes, make radical cures. 
For the removal of foreign bodies from the cornea, we are blessed 
in the possession of “muriate of cocaine.” With a two per cent, 
solution of cocaine, we can anaesthetize the eye and remove a deeply 
imbedded foreign body from the most sensitive cornea, without being 
obliged, as was formerly the case, to have to resort to the speculum 
to hold the lids, the fixation forceps to hold the eye, and an assistant 
to hold the patient. 
Concerning squint or cross-eye, much may be recommended as of 
practical worth, and laurels are likewise to be won in the non-opera- ADDRESS ON OPHTHALMOLOGY. 
5 
tive or atropine treatment of young children. A few anatomical 
points must be recognized at the outset. 
1. Note: A pair of flattened eyes with a tendency to converge 
and set in the head more or less close together—suspect far-sight- 
edness. 
2. Given a pair of prominent, bulging eyes, widely separated, 
with a tendency to diverge—suspect 7iear-sightedness. 
3. One eye alone, or both eyes alternately, or it may he at the 
same time, apparently attempting to hide behind the nose, means 
convergent squint, usually with far-sightedness, or far-sighted astig- 
matism, as a cause of defective sight. 
4. One eye or perhaps both eyes at the same time wandering to 
the outer angle of the lids towards the temples, means divergent 
squint, usually with near-sightedness or near-sighted astigmatism, 
as a cause of defective sight. 
Of course there are exceptions to every rule. According to 
Stilling (Arch. f. Augenhk. Yol. xv., p. 73), “strabismus consists 
in relinquishing binocular fixation, and placing one eye in its nat- 
ural position of equilibrium. If this is convergence, convergent 
strabismus results; if divergence, divergent strabismus ; if it is a 
parallel position of the axes, an absolute strabismus cannot result. 
In the majority of cases of nypermetropia, convergence in the posi- 
tion of equilibrium ; in myopia, divergence. 
The family physician is often called upon for an opinion concern- 
ing the nature of a squint suddenly noticed in some little one, but 
he is usually at a loss how to advise or account for the deformity. 
It will be noticed in making the squinting child turn its eyes to one 
side or the other, that one eye will be possessed of more power to 
move in extreme excursions than the other. The eye possessing the 
greatest motility is usually the squinting (non-used) eye. In order 
to compel service in the non-used eye, we usually dilate the pupil of 
the better eye, using for the purpose a four-grain solution of atropia, 
(one drop every three to five days.) Care should be taken at first 
after throwing all the wrork on the squinting eye, and, as it were, 
robbing the child of the sight of its good eye, that enough vision is 
secured to answer all ordinary purposes. We have by this method, 
generally practiced upon children between the ages of six months and 
four years, often been able to secure binocular vision and cure the 
squint, and in cases where the sight has been very poor in one eye, G 
ADDRESS ON OPHTHALMOLOGY. 
been able to convert the squint into the “alternating form,” which 
variety is the most successfully operated. 
If a child has been neglected up to its seventh or eighth year, and 
the squint is a decided one, there is nothing left but to operate. The 
success of all squint operations depends upon the amount of sight 
retained by the squinting eye or eyes. If the squint be an alter- 
nating one, we may expect success and binocular vision. Concern- 
ing other cases of convergent or divergent squint, success will be in 
accordance with the amount of vision which can be obtained from 
either eye, be the vision natural or acquired by the use of glasses. 
When there is no useful sight in the squinting eye, as is frequently 
the case, we operate simply for cosmetic effect, and must be satisfied 
with limited success. No other anaesthetic than cocaine is necessary 
in the case of adults or larger children, and this is a great comfort 
to the operator, as he can avail himself of the assistance the patient 
can render by moving the eyes as directed. 
It is all important that patients should thoroughly understand the 
ultimate results sought, Avhen advising or operating for squint. At 
times only does such an operation improve the vision ; generally it 
does not, but on the contrary impairs it for a greater or less length 
of time. When the squinting, non-used eye is called into use, and 
its indistinct image is fused with the distinct image of the fellow eye, 
it causes blurred, and often at the same time, decidedly painful 
vision. This unfortunate condition is known as muscular asthenopia. 
Muscular asthenopia causes one of two conditions: impaired 
vision, painful vision, or both. The pain caused by this sort of strain 
is one of the same sort as that Avhich we feel in the muscles of the 
arm and shoulder after carrying a heavy load. The muscles in- 
volved are the ciliary (of the pupil), and the motor muscles (of the 
globe). 
Headaches hi school children, generally frontal, although they 
may be referred to the occiput, are usually caused by defective sight, 
but rarely by diseased eyes. 
Acute disease of the interior of the eye is rarely noticed in chil- 
dren until there is actual loss of sight, and irreparable damage. The 
onset is insidious, as there are necessarily no external symptoms. 
Children are more observant than people generally suppose, and Ave 
should not fail to give ear to their oft-times significant remarks. 
Clouds and motes with corruscation, flashes of light, and kaleido- ADDRESS ON OPHTHALMOLOGY. 
7 
scopic displays of rainbow colors, suggest retinal or choroidal irrita- 
tion, and mean danger, as does the red signal light to the railroad 
man. 
Photophobia, or dread of the light, without accompanying con- 
junctival or corneal irritation, means retinal irritation, and calls for 
prompt investigation and treatment. 
Photophobia with conjunctival or corneal irritation on the other 
hand, is an ordinary symptom which can he readily accounted for 
and locally treated, and this brings us to the consideration of phlyc- 
tenular ophthalmia, which next to the purulent form is the most an- 
noying, harassing, and dangerous variety of the diseases of the eye 
to which children are subject. We will digress and attempt to paint 
a picture to he frequently seen in the office of the family physician. 
Fancy a baby between the ages of six months and three years 
carried into your office. The child is either screaming or has its 
face tightly pressed against its mother’s shoulder, one little hand 
frantically clutches her dress, while the other with equal force 
clutches a pretzel, a stick of candy, or a piece of unripe fruit. Seat- 
ing herself with a sigh, the weary mother forcibly drags the scream- 
ing child from its shelter, and endeavors to turn its face towards 
you. The face picture is typical; the eyes are closed spasmodically 
tight by the swollen eyelids, and scalding tears run down over the 
cheeks, because the swollen nose cannot provide for the overflow, 
while most significant of all is the swollen upper lip, which looks as 
if recently stung by some insect. 
The mother’s complaint is, “ Doctor, I cannot get anything done 
about my house ; this child takes my entire time. When I am not 
nursing it, it is either screaming or sleeping with its face buried in 
the pillow. I am compelled to keep the room dark, and am quite 
unable to please or manage the child.” Casual questioning elicits 
the following routine history, which goes to prove that we would 
not he much out of the way in terming this condition reflex gastric 
ophthalmia. The digestion is always disordered, and the appetite 
capricious; the child is given both tea and coffee, and very little 
milk, if any ; sweet things ad libitum, roast meats, boiled potatoes, 
pie, and a long list of indigestible food. 
The child always sleeps on its face, and the only time either it or 
its mother seems able to secure any rest is from sundown till bedtime. 
As a rule such children, to use the inelegant hut expressive phrase, 8 
ADDRESS ON OPHTHALMOLOGY. 
are “bosses of the situation,” that is, “spoiled.” They sleep upon 
their faces, buried in the pillows, which act as a warm poultice, and 
encourage congestion and swelling. 
Treatment in this disease depends upon the care and patient pains 
the doctor is willing to bestow, the faith of the mother, and the firm- 
ness she proposes to exercise in the execution of the doctor’s orders. 
It is essential that the child should be fed regularly upon simple 
food, such as milk, broth, soft boiled eggs, and rare meat (starchy 
foods are to be avoided); sweets of all sorts, as well as tea and cof- 
fee are to be tabooed. The apartments must be kept dark, and the 
child whipped, if necessary, to make it lie on its back. This plan 
of treatment once thoroughly tested, and half the fight is over. 
Locally the “yellow salve” is to be rubbed on the edges of the 
eyelids at bedtime (oxide of zinc ointment may be used for the ex- 
coriated nostrils and face). Solutions of atropia (grains one to four 
to the ounce), may from time to time be dropped into the eye, ac- 
cording to the age of the child, and also depending upon the amount 
of lachrymation; so also solutions of a two per cent, solution of 
cocaine, or we may employ a salve made of vaseline, cocaine and 
atropine in combination. 
Constitutionally we never fail to prescribe the following mixture 
to be taken at bedtime, with an occasional dose of calcined magnesia, 
because of the especial inactivity of the liver in all such cases: 
Powdered blue mass 10 to 30 grains. 
Syrup of rhubarb 1 to 2 ounces. 
S.—Shake well and give a teaspoonful or more at bedtime. 
After this has been used for a week or two, we order five drops 
or more of the syrup of iodide of iron, three times a day, never for- 
getting to prescribe bromide of potassium and syrup of lettuce 
(Aubergier’s), or some equally good sedative mixture. 
In very young children during dentition, or where flatulence and 
constipation are persistent and annoying symptoms, we cannot laud 
too highly the old Mistura foetida comp. (Dewees’ carminative). 
We have described the appearance of the child, taken for granted 
the condition of the eyes behind the firmly closed lids, suggested 
treatment, and given explicit directions, but purposely have said 
nothing until now as to how we should make an intelligent inspec- 
tion of the eyes proper, i. e. conjunctiva and cornea. You will find ADDLESS ON OPHTHALMOLOGY. 
9 
that after a mother has been compelled to assist you in holding her 
child, whilst you force the eyelids open, she will as a rule be so 
thoroughly demoralized, that in her anxiety to pacify it and get out 
of your office, she will be quite sure to forget all that you have told 
her. For this reason a few directions as to the method of holding 
such children so as to examine and treat their eyes under circum- 
stances such as we have just mentioned, will not be out of place. 
The trick is well worth knowing, as a good sized unruly child, with a 
weak mother and inexperienced doctor, where the eyes are to be 
forcibly examined and then treated, is a veritable “hull in a china 
shop.” The person holding the child is to sit directly opposite the 
physician, their knees touching, the child is to he laid upon its back, 
its body resting on the assistant’s knees, both of its feet are turned 
to one side and tucked under the assistant’s right arm. This leaves 
the assistant’s hands free to hold those of the child. To protect the 
doctor’s knees a heavy towel is spread over them, and upon this 
the patient’s head rests. In extreme cases the patient’s head may 
be pushed down and held firmly between the doctor’s knees. His 
hands are then free so that he may commence by instilling cocaine 
solution (rarely satisfactory), and with thumb and finger, or with 
any good lid-retractor, he can forcibly open the eyelids and expose 
the globe. In the disease under consideration we will find a pustule 
on the conjunctiva or the cornea, or it may be on both, or the 
cornea pustule may have developed into an ulcer. The pupil is al- 
ways contracted, and it is needless to say that photophobia is marked 
and lachrymation profuse. In either condition the treatment is as 
we have suggested, excepting one other reliable hygienic point, 
which we have thus far neglected to notice. The morning sponge 
bath is a most valuable addition, and still better is the therapeutic 
shock to be obtained by the alternate sponging with hot and cold 
water. In the case of larger children, frequent dippings of the face 
in a basin of cold water will assist materially in controlling the spasm 
of the eyelids. 
This disease is essentially one which occurs in summer, and when 
as it generally does, it accompanies dentition, or gastric or intestinal 
disease, is greatly to be dreaded. 
The only disease of the eye for which this form might be mistaken 
is what is known as scrofulous ophthalmia. This subtile inflamma- 
tion commences with what appears like a pink nodule or phlyctenule 10 
ADDRESS ON OPHTHALMOLOGY. 
on the conjunctiva, and might readily he mistaken for the disease we 
have just described. Close inspection will show that the red spot on 
the conjunctiva is not a pustule, hut a glandular swelling, accompan- 
ied by little or no conjunctivitis, photophobia, or lachrymation. In 
the majority of cases, as a guide to diagnosis, we have the scrofulous 
physiognomy, i. e., flat sunken nose, and notched teeth. Should 
this red spot have been in existence for some time, there will be 
shading from it a cloudy patch of more or less density caused by in- 
filtration between the layers of the cornea. This disease may or 
may not be accompanied by iritis, which in every instance is plastic. 
One characteristic point and never absent symptom, is the peculiar 
red coppery appearance of the inflamed conjunctiva at the limbus, 
between the cloudy spot and the inflamed gland. Arlt called this 
lymphatic inflammation of the cornea, or scrofulous keratitis, and as 
a cause always insisted upon inherited specific disease. We feel 
satisfied, however, that this form of eye disease is seen in tubercular 
subjects as well. It usually occurs between the ages of eight and 
thirty-five, more frequently at the age of puberty. In any case, no 
matter what be its origin, there is but one form of treatment which 
in our hands has proven almost a specific. We have adopted the 
German method, and in prescribing always commence with the mer- 
cury, which we gradually push to salivation, and then follow with 
iodide of potassium gradually repeated for emphasis, creeping up 
from five to sixty grains three times a day. In some cases, for chil- 
dren between the ages of eight and twelve, we have administered as 
much as one-sixteenth of a grain of the biniodide of mercury every 
hour for from one to twelve months, and at the same time used in- 
unctions of blue ointment twice daily, without being able to notice 
the slightest constitutional effect. Nevertheless we feel fully satis- 
fied that these peculiar cases not only do well, but thrive upon a 
well-managed course of mercurial treatment. As a precaution we 
always see that parents or guardians understand cases such as we 
have described, as they will require months, yea, even years, of 
prolonged and tedious treatment, and incessant looking after. We 
have not entered into more detail, because it is our intention to read 
a paper upon this particular subject at some future meeting of the 
State Medical Society. 
Opacities of the cornea, the “cataracts” of the laity, if unac- 
companied by conjunctival irritation, must be looked upon as we do ADDRESS ON OPHTHALMOLOGY. 
11 
scars upon the body, and are in a general way incurable. They may 
not be discernible save by oblique illumination, but all cause badly 
impaired vision, and strabismus or squint. If they should be the 
cause of poor sight in a hyperopic eye, the squint will likely be a 
convergent one, and vice versa. They cause dread of strong light, 
and are oftentimes a source of annoying and constant pain; and 
therefore in treating corneal disease do not be satisfied when all red- 
ness leaves the eye, but when the opaque spot remains on the cornea, 
continue your active treatment until nature fills up a clear cornea 
and removes the cicatrix. 
Concerning cataract operations much may be said pro and con. 
Every operator is an advocate of his own method, or it may be of his 
modification of somebody else’s method. Suffice to say, that the per- 
centage of success, in a general way, is so great that we are fully 
justified in assuring our cataract patients of having eight chances in 
ten of success, The more unruly or complicated cases are now 
operated on in a conservative manner. A preliminary iridectomy is 
made, and in two or three weeks later the cataractous lens is ex- 
tracted, and by this means the operation is robbed of most of its 
dangerous elements. On the other hand, in uncomplicated cases, the 
more heroic and skillful operators do not interfere with the iris,*, e., 
make no iridectomy, but remove the lens through the dilated pupil, 
being bold enough before commencing the operation to wash the eye 
and its tutamina with soap and water, and by way of antisepsis in- 
ject an antiseptic solution into the eye, 
In operating for cataract, we must be particularly careful where 
solutions of cocaine are used, as a local snsesthetic, and not expect 
to do more than render the conjunctiva and cornea anaesthetic. If 
we use enough of a two per cent, solution of cocaine to aft'ect the 
iris, there is risk of having the corneal flap shrivel, and we have con- 
cluded that unless an operator be satisfied with anaesthesia of the 
conjunctiva and cornea, he must frequently sacrifice an eye. We 
seldom bandage an eye after cataract operation now, prefering to 
use adhesive plaster (as first suggested by Dr. R. J. Levis) cut into 
half ovak to fit the upper lid. 
Cataracts are artificially ripened by massage, when for several 
reasons we do not wish to wait for nature, and a puncture of the 
lens or a preliminary iridectomy is often made for the same reasons. 
In examining the eyes of those past middle life, a two per cent. 12 
ADDRESS ON OPHTHALMOLOGY. 
solution of cocaine is the safest and therefore the best mydriatic, 
because of its evanescent character, and its tendency to reduce intra- 
ocular pressure. In our private as well as clinical practice, we use 
cocaine in two per cent, solution, for all preliminary examinations, 
never using any other mydriatic, except when we wish to paralyze 
the accommodation. Solutions of atropine are too heedlessly used 
and the number of cases of atropine glaucoma are steadily increasing, 
as can be found out by looking up the literature of the subject. 
For glaucoma we have a potent local remedy in the form of 
“ eserine” (the alkaloid of the extract of calabar bean), which may 
be instilled in solutions of varying strength Q to ij grains to i f.§), 
and by this means an eye may either be cured or at least kept under 
control until the surgeon is able to operate (make an iridectomy), 
paracentesis of the anterior chamber, etc. In fact numbers of cases 
have been entirely cured by the instillation of this drug alone. 
In detachment of the retina occurring in myopic eyes, we have 
had most gratifying success by treating the condition as if it were a 
traumatic sub-retinal effusion due to other causes than myopia, and 
employing a full specific course with absolute rest. We commend 
hydrarg. pushed to poisonous effects both by pill and by inunction, 
to be followed by iodide of potassium, not forgetting to recognize the 
like effect of jaborandi (internally) or pilocarpin (hypodermically). 
In the selection of spectacle frames—note we did not say spec- 
tacles—opticians are universally careless, and those who prescribe 
glasses are culpably negligent. If the spectacles are intended for 
reading or near work, the bridge piece is often made shallow, so that 
in casting the eyes down the lower edge of the lens is in the way, 
and seeing over the top of the glasses is an impossibility. If the 
spectacles are for near work, they should have a deep bridge-piece, 
which will enable the wearer to drop the eye (as for reading, etc.), 
and have it strike the center of the glass, and the next moment, with- 
out moving the head, be able to look over the glass, and in the dis- 
tance. If on the other hand the glasses be for distance, they should 
have a shallow bridge-piece, and be set well up in front of the eyes, 
so that the wearer cannot do otherwise than look through them for the 
distance, and under them in front when walking, etc. Where 
double lenses are used, the upper half for distance and the lower 
half for near, their manufacture must in every case be intrusted to 
the care of a skilled optician. Each half, glass must be ground from ADDRESS ON OPHTHALMOLOGY. 
13 
a whole lens to secure a proper optical centre. One half of the lens 
will not do. The great want of care displayed in the manufacture of 
this form of glass has been the cause of bringing it into disfavor. 
Protective glasses are best made of number four “ London 
smoke” glass. Too light a shade does not offer protection enough, 
while on the other hand too dark a shade causes too severe and sudden 
transition from dark to light. Oculists for many reasons prefer the 
smoked, that is dark glass, and so, if left to themselves, do the 
majority of persons. Take for instance one hundred purchasers of 
protective glasses, as they select them from the vendor on the sunny 
sea shore, and ninety of them will select the dark or “ London 
smoke.” Green at one time, copying after Nature, was the fash- 
ionable color; afterwards everything was “blue glass;” but ex- 
perience has selected the smoked. 
We want to refer to another sort of protective glass, i. e. those 
worn to keep foreign bodies from damaging the eyes. For this 
purpose glass and mica as well as wire-gauze have been used, es- 
pecially in the older countries, but we are sorry to say our mechan- 
ics do not seem to know how, or to want to take care of themselves. 
In this country of profligate waste of money and life, we are in the 
course of a year compelled to enucleate too many damaged eyes 
which might have been saved by protective glasses. 
In a general way we would advise near-sighted people to wear 
eye-glasses ; far-sighted people should wear spectacles; those who 
must wear glasses constantly, or who have astigmatic eyes, in every 
case ought to wear spectacles. Cylindrical glasses should always 
have the direction of the axis marked by a scratch on the edge of 
the glass. 
We would have much more to say but time forbids our narrating 
many wonderful, valuable and interesting novelties which we had 
prepared as an addition to this paper. 
1719 Chestnut Street.